Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
International Journal of Current Microbiology and Applied Sciences
ISSN: 2319-7706 Volume 5 Number 3(2016) pp. 1-8
Journal homepage: http://www.ijcmas.com
Original Research Article
http://dx.doi.org/10.20546/ijcmas.2016.503.001
Epidemiological Trends over a Ten-year Period of Malaria
in a non-Endemic Area of Saudi Arabia
Hamdan I. Al-Mohammed1 and Mounir S. Ferchichi2*
1
Department of Medical Microbiology and Parasitology, College of Medicine, King Faisal
University, P.O. Box: 400, AlAhsa 31982, Saudi Arabia
2
Public Health Department, College of Applied Medical Sciences, King Faisal University, P.O.
Box: 400, AlAhsa 31982, Saudi Arabia
*Corresponding author
ABSTRACT
Keywords
Epidemiology,
Malaria,
Plasmodium,
Al-Ahsa,
Saudi Arabia
Article Info
Accepted:
07 February 2016
Available Online:
10, March 2016
This study aimed to determine the epidemiological characteristics of imported
malaria infections in Al-Ahsa, Eastern province of Saudi Arabia, based on a
retrospective analysis of central laboratory records over the last ten-year period
from 2005 to 2015. Records showing details of all positive slides for malaria
blood films over a 10-year period were analysed. The focus was on identifying
the common types of malarial parasites in the area, the nationality and the age
of the patients. 631771 patients were screened for malaria during the 10-year
period of which 692 slides (0.1%) were positive. Mean annual positivity was 63
slides/year. Out of the positive slides 527 (76%) showed Plasmodium vivax, 79
(11.5%) showed Plasmodium falciparum, 71 (10.5%) showed Plasmodium
malariae and 15 (2%) showed a combination infections. The prevalence of
malaria continues to be low in Al-Ahsa. Among the affected patients, the vast
majority are expatriates indicating that most of the infections are imported
cases.
Introduction
The incidence of malaria, which takes into
account population growth, is estimated to
have decreased by 37% between 2000 and
2015 (WHO, 2015). In humans, the disease
is induced by different species of protozoa
parasites from the genus Plasmodium. The
most severe form of the disease is related to
Plasmodium
falciparum,
which
is
responsible for many deaths every year
(World Health Organization, 2014).
Malaria-associated symptoms appear during
the blood stage of the disease with infection
Malaria is a serious public health problem, is
a worldwide health risk leading the death of
millions of people (Leandro et al., 2016).
The number of malaria cases globally fell
from an estimated 262 million in 2000 to
214 million in 2015, a decline of 18%
(WHO, 2015). Most cases in 2015 are
estimated to have occurred in the WHO
African Region (88%), followed by the
WHO South-East Asia Region (10%) and
the WHO Eastern Mediterranean Region
(2%).
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Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
of erythrocytes. Erythrocyte invasion by
Plasmodium has always been credited to
parasitic
mechanisms
and
host-cell
participation regarded as passive (Leandro et
al., 2016). In humans, Plasmodium
falciparum is the most dangerous species
responsible for severe disease. Resistance to
existing drugs has developed in several
strains and the development of new effective
compounds to fight these parasites is a
major issue. Despite all efforts to establish
the pathogenesis of malaria, it is far from
being fully understood.
planners at each level for assessing progress
and focusing future efforts while providing
evidence-driven public health action in
preventing
and
controlling
malaria
incidence.
Malaria is the most important disease
transmitted by mosquitoes (WHO, 2015) of
the genus Anopheles, with 482 species
identified in the world (Harbach, 2015).
Almost 70 species of Anopheles have been
incriminated as the vectors of malaria in the
world (Sinka, 2013), among which about 41
species are considered as the most important
vectors (Enayati et al., 2010). Mosquitoes
(Diptera: Culicidae) are a big and plentiful
group of insects that occur all over the
temperate and tropical areas of the world.
Based on the current classification,
mosquitoes include two subfamilies, 112
genera and 3,543 species (Harbach, 2015).
Genus Anopheles includes seven subgenera;
also genus Culex includes 26 subgenera
(Harbach, 2015). There are a few reports on
indices of association between larvae of
mosquito species in various habitats in the
world (Service, 1968; Wooster and Rivera,
1985; Marcondes and Paterno, 2005; Nagm
et al., 2007). Accurate assessments of the
levels and time trends in malaria burden are
crucial for the assessment of progress
towards goals and planning national health
services and focusing future efforts (Murray,
al., 2010; Cibulskis, et al., 2010). The study
provides scientific evidence that would be
an important database of local, national, and
global relevance in advancing current
knowledge on malaria situation. It is also
useful to policy makers and program
Materials and Methods
The aim of this study is to determine the
trend of malaria prevalence in the last tenyear’s period from 2004 to 2014 and
describing malaria occurrence in Al-Ahsa,
Eastern province of Saudi Arabia. One of
the primary goals of our study was to assess
the load of imported malaria in our sample.
Study Area and Period
The study was a retrospective analysis of all
recorded cases of malaria over a ten-year
period from 2004 to 2014 based on records
kept by the Saudi Ministry of Health for AlAhsa region in the Eastern province.
Source Population
A total of 631771 records of patients in AlAhsa province was the source population of
the study. All available records of reported
cases were analysed and the focus was on
the type of malarial parasite identified and
on the age and nationality of the affected
patients. 631771 records of patients
presenting with fever and who had blood
films prepared to rule out malaria were
screened. We also attempted to study the
pattern of the nationalities of the expatriates
affected. The study also attempted to
analyse the common mosquito species
isolated from the region under study based
on records of light traps and larval
screening.
Data Collection Procedure
Medical laboratory technicians or nurses
collected Blood sample. Malaria report data
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Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
collection form including name of Hospital,
year, month, date, sex, age, and nationality
of each record.
(1.7%) were Saudi patients. All the rest 680
(98.3%) were expatriates. The break-up of
nationalities was analysed for the year 2012.
Of the 131 cases showing slide positivity, a
majority were from the Indian sub-continent,
of which 59 were Indians (45.3%) and 48
were Pakistani (36.9%). The other expatriate
nationalities included 11Ethiopians (8.4%),
9 Sudaneses (6.9%) and one Yemeni (0.7%)
(Figure 3).
Data Processing and Analysis
Different data including age, sex, hospital
name, year, and country was entered by
date. Data and analysis were performed by
Excel program. Line graphs are used to
depict the overall as well as specific trends
of malaria prevalence in the last ten years.
A screening of the mosquito species in the
same year found that the major species of
mosquito in the region was Culex
mosquitoes (79%, which signify 457) and
the second common species was the
Anopheles (21%, which signify 121).
Screening of larval breeding sites showed
Aedes species as well, but light traps /adult
mosquito screens did not show any Aedes
mosquitoes. Out of 5811, we had 3843 cases
(66.1%) were Culicine larvae, 1940 (33.3%)
were Anopheline and 28 (0.4%) were Aedes
larvae. As far as age, distribution was
concerned, the vast majority (683) of cases
were above 15 years of age and symbolise
98.6%, and only 9 (1.4%) pediatric cases
being recorded.
Data Quality Management
National standard of malaria diagnosis and
laboratory examination of blood films was
respected.
Results and Discussion
Out of 631771 patients, were screened for
malaria during the 10-year period, 692 slides
(0.1%) were positive for malarial parasite.
Mean annual positivity was 63 slides/ year.
The number of infections recorded showed a
general upward trend in recent years (Figure
1), though there was a decline in the
incidence during the years 2007 (21 cases)
and 2008 (23 cases). From 44 cases in 2004,
the number has approximately tripled to 131
cases in 2014 (Figure 1).
An effective malaria control program, which
started in 1948, has ensured that indigenous
cases of malaria are rare in the Eastern
province of Saudi Arabia. The incidence of
malaria in Saudi Arabia is highest in the
Southwestern regions of Jizan and Asir.
However, cases of imported malaria
continue to occur in the Eastern province.
This study describes the epidemiological
trends related to malaria in Al-Ahsa region
of the Eastern province over a ten-year
period (2004-2014). The malaria control
program in Saudi Arabia started in the year
1948 and the strict implementation of the
program has ensured that the incidence and
spread of malaria in the Eastern province of
Saudi Arabia remains low. As of now active
malaria transmission in Saudi Arabia is
The predominant parasite identified was
Plasmodium vivax. Out of 692 positive
slides, 527 slides showed Plasmodium vivax
(76%). The second most common was
Plasmodium falciparum (Figure 2). Out of
79 slides, eight slides (11%) showed
Plasmodium falciparum. In the remaining 71
slides, (10%) showed Plasmodium malariae,
and 15 (2%) showed a combined infection
(Figure 2).
As far as nationalities were concerned, the
overwhelming numbers of cases were
expatriate patients. Only 12 out of 692
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Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
mainly localized in the South and SouthWestern areas of the Kingdom, especially
Jizan area (Alkhalife, 2003). The last major
analysis of the epidemiology of malaria in
the Eastern province was that of Al-Tawfik
(Altawfiq, 2006) who had conducted a
retrospective analysis of the epidemiology
of malaria over a period of 10 years (19942005) in Dhahran (Altawfiq, 2006). This
study was based at the Saudi Aramco
Medical Services Organization. Of a total of
about 370000 individuals screened for
malaria, 56 cases positive for malarial
parasites were seen, with a mean annual
incidence of 3.5. In this study, also the
majority of cases showed Plasmodium vivax
(54.4%). All infections were presumed to be
imported cases and the most frequent
countries of acquisition were Pakistan, India
and the Sudan. In our study, also the major
nationalities were Indian and Pakistani
(Altawfiq, 2006). Our study also showed a
significant number of Ethiopian expatriates,
besides the Sudanese nationals. The
importance of screening all expatriates for
malaria to control the introduction of
imported malaria and further complications
like drug resistant malaria needs to be
highlighted in future malaria control
programs. The type of parasite appeared to
follow the area of acquisition as the only
Saudi patient during the year 2014 had
Plasmodium falciparum, while Plasmodium
vivax was the main parasite amongst the
expatriates. Plasmodium falciparum has
been shown to be the most common parasite
in the endemic areas of Saudi Arabia
(Alhassan and Roberts, 2002), while
Plasmodium vivax is the most common in
the Indian sub-continent (Eliades et al,
2005). The Sudanese patients in our study
had an almost equal incidence of
Plasmodium falciparum and Plasmodium
vivax even though the predominant species
in Sudan is Plasmodium falciparum (Adam,
et al., 2005). A study from Riyadh, Saudi
Arabia, by Alkhalife (Alkhalife, 2003) based
on the records of the malaria referral
laboratory over a 6-year period from 1996 to
2001 also showed a high percentage of slide
positivity among expatriates, in this study,
positive slides included Saudi (36.6%),
Sudanese (30.9%), Indians (13.9%),
Pakistanis (8%) and Yemenis (5%).The
majority of the affected patients in the
aforementioned study were adults unlike in
our study where a significant number of
cases were below the age of 10 years (25%
of the total cases) (Altawfiq, 2006). The
other major study conducted in the Eastern
region of Saudi Arabia was a clinical,
epidemiological and haematological profile
of laboratory diagnosed malaria cases at a
tertiary care university hospital in Al
Khobar, Saudi Arabia by Bashawri
(Bashawri, et al., 2001). In this study, there
were 602 cases with a mean age of 25.8. The
majority of the cases were expatriates
(58%). Plasmodium falciparum was the
most common species among Saudi,
Sudanese and Yemeni patients, while
Plasmodium vivax was predominant among
other expatriates. Most of these cases had a
history of travel to their home countries. The
most common clinical features of the
malaria cases in this study included: fever
(97%), splenomegaly (9%) and jaundice
(8%).
Anaemia
(60%)
and
thrombocytopenia (53%) were the most
common haematological findings (Bashawri,
et al. 2001).
A previous study by Alahmed (Alahmed, et
al., 2012) has shown that all species of
mosquitoes are seen in Al-Ahsa. The
predominant species was found to be Culex
mosquitoes but there were a significant
number of Anopheles mosquitoes also. Our
study corroborates these findings. Culex
mosquitoes were identified as the majority
species both in adult and larval screening,
while anopheles mosquitoes were the second
most common.
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Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
Figure.1 Annual Malaria Cases in Al-Ahsa from 2004 to 2014
Figure.2 Distribution of the Identified Malarial Parasites (692 Cases) for the Period Between
2004 and 2014 in Al-Ahsa, Eastern Province of Saudi Arabia
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Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
Figure.3 Number of Ases of Malaria by Nationality from 2004 to 2014
Aedes mosquitoes were seen in larval
screening sites but not in light traps/adult
screens. Considering that there is a viable
presence of the vector mosquitoes and the
presence of active malaria cases, continuing
active surveillance for the effective control
of malaria in this region is essential. It
should be noted however that the ambient
temperature and high aridity may be a
significant contributing factor for limiting
the spread of malaria in the Eastern
province, which is characterized by
relatively high extremes of temperature with
summer temperatures frequently crossing
50ºC. Ambient temperature can affect the
transmission of human malaria based on its
relationship with the duration of sporogony
of the parasite in the mosquito. Extreme
aridity adversely effects Anopheline
development and survival (Almaza, et al.,
1999; Snow, et al., 2013).
South-Western region of Saudi Arabia,
careful monitoring of important malaria and
associated spread of drug resistant strains
needs to be under regular surveillance.
Screening of all expatriates during the initial
entry into the Kingdom and strict screening
before procedures like blood transfusion
should also be implemented (Saeed, et al.,
2002; Alkhalife, 2003). A study by Al-Farsi
(Alfarsi, et al., 2012), has suggested that the
primary source of drug resistant cases of P.
falciparum in the South-Western area of
Saudi Arabia is most likely from East Africa
(Alfarsi, et al., 2012). The Eastern province
has also a very high number of expatriates,
including from malaria endemic countries,
who could be a potential source of imported
malaria.
The main limitations of our study include a
lack of clinical correlation, as we did not
have sufficient data regarding the clinical
presentation of the positive cases. Detailed
patient history regarding the acquisition of
the disease was not available, hence we
could not confirm if all the cases were
indeed true imported cases. We also did not
have data for the treatment details.
A
challenge
to
the
successful
implementation of the malaria control
program in Saudi Arabia is the high influx
of expatriates and visitors to the holy places
from malaria endemic countries. Though
this is mainly a problem in areas like the
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Int.J.Curr.Microbiol.App.Sci (2016) 5(3): 1-8
In conclusion, the prevalence of malaria
continues to be low in Al-Ahsa area of the
Eastern province of Saudi Arabia. Among
the affected patients, the vast majority are
expatriates indicating that most of the
infections are probably imported cases.
Considering the large number of possibly
imported cases, effective vigilance for cases
of malaria needs to be strictly continued.
Malaria remains as a public health problem
in the study area with relatively high slide
positivity rate.
Alfarsi, H.M., Alhashami, Z.S., Bin Dajem,
S.M., Alqahtani, A., Beja-Pereira, A.
2012. Source of drug resistant
Plasmodium falciparum in a potential
malaria elimination site in Saudi
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1259.
Alhassan, N.A, Roberts, G.T. 2002. Patterns
of presentation of malaria in a tertiary
care institute in Saudi Arabia. Saudi
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Alkhalife, I.S. 2003. Imported malaria
infections diagnosed at the Malaria
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Almaza, A., Fontaine, R.E., Al-Saigul, A.M.
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Altawfiq, J.A. 2006. Epidemiology of
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Bashwari, L.A., Mandil, A.M., Bahnassy,
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Recommendation
According to our results, we strongly
forward the following recommendations:
exceptional attentions need to be reflected
for visitors to the Kingdom. Further studies
should be conducted to determine or forecast
potential epidemic patterns in the study area;
public awareness conception could be
implemented; strong emphasis should be
given to malaria prevention and control;
performance plans and achievements should
be regularly and strictly reviewed and
evaluated at each level.
Acknowledgement
Authors would like to thank the Deanship of
Scientific Research King Fiasial University
for financial support of this project.
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How to cite this article:
Hamdan, I. Al-Mohammed, Mounir, Ferchichi, S. 2016. Epidemiological Trends over a Tenyear Period of Malaria in a non-Endemic Area of Saudi Arabia. Int.J.Curr.Microbiol.App.Sci.
5(3): 1-8. doi: http://dx.doi.org/10.20546/ijcmas.2016.503.001
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